A Concept Analysis: The Grieving Process for Nurses
The ORIGINAL 4 40 Grieving © by 0029-6473 Process for Nursing USAARTICLE NUF Nursecom, Malden, Forum Inc. Inc Nurses Blackwell Publishing 2005
Tina Brunelli, RN, BSN
The concept of the grieving process has been explored extensively in families losing a loved one
Tina Brunelli is an MSN/FNP student at the WinstonSalem State University, Winston-Salem, North Carolina. A Concept Analysis: The Grieving Process
or in a patient grieving over a terminal diagnosis. The patients and families live through this experience one time. What about the nurse who lives it several times a week by caring for these patients and families? How does a nurse grieve? Little publication and research have been done surrounding the grieving process for nurses. This is a concept analysis that clarifies the grieving process for nurses. Clarifying this process will enable further development of nursing research and education, ultimately benefiting nursing practice and retention. Search terms: grieving process, nurses
A nurse working in a bone marrow transplant unit admits a 15-year-old female patient for her second allotogenous transplant. The patient will receive her stem cells from her 12-year-old brother, just as she did with her first transplant less than 2 years ago. This young, vibrant, seemingly healthy young woman brought with her hopes of a cure. Unknown to me, that young woman also brought with her a lesson in grieving that I had not experienced in 19 years of employment. The patient died a horrible death, 65 days after her transplant. She endured graft-versus-host disease involving not only her gastrointestinal tract, but also her liver. She developed acute respiratory distress syndrome (ARDS) from an alveolar bleed as a result of the highdose chemotherapy and her low platelet count. She eventually required mechanical ventilation and then tracheotomy after being on the ventilator for over 3 weeks. Her parents stayed by her side day and night for months. I was the patient’s primary nurse every day that I worked. I was off the day she died. Everyone who knew her grieved for her. The grieving process is a concept that all nurses need to examine, because grief is a phenomenon that every human being will eventually experience. How do nurses grieve the loss of their patients? Especially nurses who deal with patients who frequently have prolonged suffering with little comfort care in the name of a cure? My personal beliefs are that, too frequently, nurses are expected to “deal with it” or help the family or patient cope. However, who helps the helper? Who assists the nurse who spends hours every working day dealing with the suffering and trying to make it “better” when she or he knows that nothing she or he does would really help make it better? How does the nurse work through such a loss? Clearly, the grieving process needs to be understood among healthcare providers.
Volume 40, No. 4, October-December, 2005
However. but never have I been in a class that presented how to teach a family or patient to grieve. and acceptance. concept analysis allows one to explore the attributes or characteristics of a concept. but the goal is a healthy resolution of the loss or sorrow so the person can proceed through life. Furthermore.The Grieving Process for Nurses
How do nurses grieve the loss of their patients?
Definitions According to Walker and Avant (1999). adjusting to the environment from which the deceased is missing. Papadatou. and reorientation and recovery (resolution of previous strong felt emotions). 1996). Many articles and studies have been written in relation to the nurse helping the patient with his or her grief or the nurse helping the family work through the process of losing a loved one. but never have I been in a class that presented how to teach a family or patient to grieve. We as nurses learn how to care for patients in all aspects of life and death. anger (at the loss or about being ill toward people or God). or to feel grief or sorrow. a natural continuing activity or function. No. Most of these articles spoke of how the nurse was specially trained to deal with and teach the grieving process to lay persons. grieving means to cause to suffer. 2005
. and then moves on with one’s life (Reese. Papazoglou. experiencing the pain of the loss. October-December. disorganization and reorganization (stopping old actions then replacing them with new actions or resuming actions that contribute toward closure of the process). Unlike Kubler-Ross. The grieving process is how you reconcile your personal feelings of loss. Concept analysis is a careful examination and description of a word. Pessagno (2002) lists four tasks of grief that are described as follows: accepting the reality of the loss.
We as nurses learn how to care for patients . . numbness and anger). and
Nursing Forum Volume 40. The purpose of a concept analysis is to distinguish between concepts. Clearly. Based on Merriam-Webster’s Online Dictionary (2004). It is the way one develops a peace with one’s self in relation to a loss. Process is defined as a natural phenomenon marked by gradual changes that lead toward a particular result. Bellali. depression. bargaining (is there another way).
and withdrawing energy from the relationship with the deceased and reinvesting in other relationships.
On the other hand. or a series of actions or operations conducing to an end. Kubler-Ross (1969) defines the grieving process as moving through the five stages of grieving: denial (denying the presence of loss or disease). there were very few studies and articles found related to how the nurse deals with the loss of a patient. Stephenson (1985) describes the grieving process in three phases: reaction (involving shock. Literature Review I searched medical and nursing databases for the concept of the grieving process. This process is marked with stages or steps that may vary from individual to individual. 4. These articles included studies on what actions by the nurse or physician made the family more comfortable with the patient’s death or impending death. I must have missed that semester in nursing school. . all of the above definitions of the grieving process revolve around an individual feeling of loss or sorrow then working toward a healthy resolution of this loss or sorrow.
Furman (2002) states that helping nurses deal with death and process grief guards against burnout. The resolution or acceptance of the loss results in the individual being able to establish or invest in other relationships and move on in a healthy fashion throughout the rest of his or her life. volatile reactions. Contrarily. sorrow. Furthermore.Petraki (2002) explored grief responses of Greek nurses who provided care to children dying from cancer. 1999). Bauer. 4. The nurse must not repress his or her grief for the sake of looking strong or in the name of looking professional. Consequences According to Walker and Avant (1999). and difficulty concentrating. anger. Similarly. The nurse must work through the stages of the grieving process until a healthy resolution and acceptance of the loss is obtained. Brosche (2003) established a Grief Care Plan for the nurse to assist the nurse through the grieving process. Lenart. Some nurses reported grief responses such as fatigue. Defining Characteristics/Attributes Defining attributes are a list of characteristics of a concept that appear over and over again when reviewing the literature. Support was found from other nursing staff by recalling the positive attributes of the child and discussing positive contributions the nurse had made to make the child’s death more peaceful. loss and loneliness. and Milligan (1996) presented an article where an oncology nurse experiencing the loss of a patient receives assistance from the beginning of the patient’s diagnosis. reorganization. Puckett. and recurring thoughts of the dying conditions (pain and suffering) and the actual death of the child. This approach used a support group for nurses. Just as important. The nationwide consequence being an even larger nursing shortage. Hinds. The support is continued through to the death of the patient. The process of working through loss was significantly compromised and led to various degrees of burnout. Most frequently. The researchers found that nurses fluctuated between experiencing and avoiding their grief. No. such as alcohol and drugs or even to thoughts of suicide. finally. in return. They help you name the occurrence of the concept as differentiated from a similar concept (Walker & Avant. maintains a therapeutic presence. 2005
nurse must experience a loss or perceived loss. the consequences of not going through the grieving process for the nurse can range from burnout to potentially harmful addictions. the
Nursing Forum Volume 40. Likewise. The grieving process has the defining characteristic of being a loss that causes grief. leads to better patient care. All being documented unresolved grief responses. moodiness. disorganization. Johnson. relief. and depression. As Brosche (2003) tells us. sadness. consequences are the events or incidents that occur as a result of the occurrence of the concept. anger. In order to experience the grieving process. The diagnoses used for this plan were shock. reestablishment. denial. Brighton. guilt. and. sleep disturbances. and Stringer (1998) found that nurses mainly repressed grief and that their support systems were mainly from other nurses. which involved a multidisciplinary team to assist nurses through the stages of grieving until acceptance was reached. 2002). Antecedents Antecedents are the events that need to take place prior to the occurrence of the concept (Walker & Avant. The loss is then processed to acceptance or resolution of this loss through stages such as denial.
. October-December. Resolution enables the nurse to be fully present for his or her patient (Furman. The consequences for the hospital can lead to high turnover and decreased customer service and satisfaction. anxiety. the nurse avoided the grief and was noted as saying that a curtain was drawn down and the pain was forgotten. Reactions ranged from crying. and. Charise. disorganization. staff morale and delivery of patient care can be affected. or the pain was placed in a drawer and closed away. 1999).
received excellent nursing care. I often found myself unorganized or disheveled especially at home as I wondered how my patient was doing. however. In my prayers. She changed preceptors so she did not have to take care of my patient. which includes all the defining attributes and no other attributes. I felt a lump in my throat every time I had to go into her room and face the agony she and her family were experiencing. and. One day. I remember her mother discussing with me if she made the right decision by
. I was the patient’s primary nurse. She told me that sometimes it was even hard for her to come to work. which meant taking care of my patient. No. Jennifer was waiting for me and said that she was not sure she could do this job. I saw Jennifer start to try to block out her feelings. leads to better patient care. This case. When Jennifer did have to work with me. I taught her and her family the routine and not-so-routine side effects of her treatment and prepared everyone involved for the possibly rocky road ahead. helping nurses deal with death and process grief guards against burnout. in return. 1999). I held her as she wept and became angry because I could not tell her “yes” anymore. . I became depressed. I cried with her and her daughter as they said goodbye to each other before the patient was sedated then intubated. No one knew if she would ever wake up again. I was working the days when she was developing ARDS. October-December. I knew my patient was taking a turn for the worse and I made sure Jennifer also knew this. We were working the days when the patient was developing ARDS. It became hard to even go to work. As time proceeded. She assisted me when I delivered the patient’s chemotherapy. Jennifer
Nursing Forum Volume 40. but she just walked away. Borderline Case A borderline case is a case that contains some of the defining attributes of a concept but not all of them (Walker & Avant. She started to find herself unorganized at work. that when our unit gets an especially young patient. Jennifer was present when I taught the patient and her family the routine and not-so-routine side effects of her treatment and prepared everyone involved for the possibly rocky road ahead. .The Grieving Process for Nurses
. Jennifer showed signs of being depressed. maintains a therapeutic presence. she did only immediate patient care. as a result. limiting her personal presence in the room so conversations could not get too in-depth.
making her daughter a DNR. I cried with her parents and said goodbye to her before she died. maintain close relationships with patients. As time proceeded. I tried to discuss her feelings. the patient’s mother started to cry as she asked me if her daughter would live. 4. I went through the grieving process and. One day. I delivered her chemotherapy. After the patient’s death. I attended a grieving support program for nurses at the hospital. is an absolute instance of the concept (Walker & Avant. 1999). I was present the night the patient had a massive myocardial infarction then went pulseless. They. I held her as she wept. Jennifer was not working the night my patient died. When I left the room. She also attended the grieving support group at the hospital. she was my orientee when I cared for the patient. I notice. 2005
Model Case A model case is constructed to illustrate the concept of the grieving process. I prayed for her recovery and I swore I would never complain about working too hard or being understaffed again. Jennifer was not my patient’s primary nurse. in return. I was present the day the doctor had the “end of life and do not resuscitate (DNR)” talk with the patient’s family. the patient’s mother started to cry as she asked me if her daughter would live. She sent a sympathy card to the family for closure.
October-December. including her husband. and patient’s family. “They all die anyway. When the patient died. The son is distracted and cannot even hunt because he cannot shoot his bow straight enough to hit his prey. 1999). The chief’s son becomes angry and confrontational with anyone who even mentions his father’s name. She knew that the patient’s prognosis was poor from the very beginning. Therefore. The medicine man speaks to the Great Spirit and tells him that if the great leader could come back. She left the room while the family viewed the body. During the cremation of the leader. the chief’s son receives a message from the Great Spirit that his father’s spirit will be by his side through all his decisions as new chief. “I will hit a home run every time and show coach that I am not a baby! I’m not sad anymore. The rest of the boys are aged 7 to 9. He is the only 6-yearold on the team. She hated her job and everything about it. Invented Case According to Walker and Avant (1999). The tribe must go through the grieving process in relation to his death. an invented case is a case that uses the ideas of the concept but outside our own experience. She eventually quit bedside nursing altogether and now works at an insurance company. After the tribe hears of the promise of hope. When she does take care of these patients. Contrary Case A contrary case is a clear example of what the concept is not (Walker and Avant.” My son had worked through his sadness by reasoning that he would also be big someday. The young son tells the medicine man of his premonition. My son is very tender hearted. the patient. even in another form. She took care of my patient during the days I was not working. The tribe says goodbye to their leader. 4. Sue was my patient’s other primary nurse. and every year on the anniversary of his death. they sing his praises. The following is an invented case. My son was crushed. During a time of chanting. My son is in his first year of coach pitch baseball. Why even try?” Sue displaced her anger on the other nurses and became confrontational with even the slightest disagreement. he will be the one hitting the ball hard. his next game he went three for three and hit a triple over the third baseman’s head. Sue left the floor so she did not have to say goodbye to the patient’s parents. She left the room when the patient’s parents cried because she just could not deal with the emotion. 1999). 2005
The coach told my son that he could not play his usual position because the team needed someone bigger on the pitcher’s mound so that if they got hit by a ball. An Indian chief who had ruled his tribe for many decades dies from old age. She refused to talk about her feelings with anyone. The following is a related case on sadness. to lead their people. they would not get hurt. she gives excellent nursing care. All the kids on the other team were aged 9. Mommy. Related Case Related cases are instances of concepts that are similar to the concept being studied but do not contain the critical attributes (Walker & Avant. the tribe rejoices. Sue eventually became depressed and felt worthless. but stays distant. I told him that when he gets older and bigger. Seeing the patient decline in status and develop ARDS. By the way. Sue shed no tears. The chief will live on in his son’s actions and deeds. he would do any thing that the Great Spirit asks of him. She said phrases like.
Nursing Forum Volume 40. He told me after the game with tears in his eyes that he was sad. Sue became angry. the women cry while the men chant and beat drums. they hit the ball much harder than the other teams did. She mentally tried to block out any caring or link between herself.
.tries very hard to avoid taking care of that patient. My son looked at me and smiled and said. No. The son becomes a great and decorated leader as his father was. making the smaller kids go to the outfield because he will hit the ball even harder than any of the other kids on his team. The other team was also undefeated. He asked his coach to play pitcher during one of the biggest games the team had this year.
it’s okay for you to grieve too. I. including not just physical but mental and spiritual as well. Furman. Johnson.) Englewood Cliffs. and the ICU nurse. with a copy to the Editor: cooperconsulting@socal. 2004.
Author contact: mpbgjb@yadtel. Bauer. P. Greek nurse and physician grief as a result of caring for children dying of cancer. Death. D.A. pastoral care.com/cgi-bin/dictionary?book=Dictionary Papadatou. On death and dying. Retrieved October 27. T. 14. drink. NJ: Prentice Hall. Please cry with your patients and their families. (1969).. Reese. 2005
. & Petraki. we need to take care of ourselves so we can survive and thrive in our environment. tell stories. maladaptive grieving can lead to emotional distancing and depression. with the final result of fewer nurses leaving the field. These memorial services need to be mandatory for anyone not working that day. we will all experience the loss of a patient at some time in our career. all people present. (1998).”
I believe Reese (1996) says it all when he wrote. anger. Bellali. “Hey. (2002).. Pediatric Nursing. Journal of Nursing Staff Development. 173–179. New York: The Macmillan Company. Brighton. T. K. 4. Stephenson. Nursing. At a time when we live with a continuing nursing shortage. grief. J..rr. and psychology. Kubler-Ross. to grieve. 48–53.net. 2004. 56–57. but it is a very healthy start. Who supports you when your patient dies? RN.. laugh. (1999).m-w. and just have some closure together.
“. Grief support for nursing staff in the ICU. This maladaptive grieving results in the loss of nurses to other professions or nurses who give poor nursing care (Brosche. L. when a person who’s influenced you in some way has died. Pessagno. 59(5). J. loss. . No. The grieving process involves going through steps to arrive at a resolution
or acceptance of the loss or death. (1996). 22(4). from http://www. Grief.C. October-December. 32(2). E..M. need to have time to eat. Three to four times a year. mental.C. Merriam-Webster Online Dictionary (2004)... Strategies for theory construction in nursing (3rd ed. Lenart.
Volume 40. physicians.S.. and spiritual health. either in the chapel or in a church. Retrieved October 21. This intervention may not completely cure the nursing shortage. Papazoglou. New York: The Free Press.com References
Brosche. and bereavement. Joanette McClain for her guidance and encouragement. but also mental and spiritual burden on us not only as nurses. Nursing needs to stand up and say. Conclusion In summation.D.” Acknowledgment. 26(8). J.B..G. & Stringer. Acknowledgment is to be given to Dr. R. and mourning. Death. M. to cry.S. we hurt too. 28(4). For nurses who work in settings that revolve around patient diagnoses that have poor prognoses.. Nursing.J. the repetitive loss of patients puts not only a physical. non-caring. T. but also as humans. (2002). D. memorial services need to be held for the ones that have passed. & Avant. and burnout. S. (2002).The Grieving Process for Nurses
Implications for Nursing As nurses. What you should know about chronic grief. After the short service. (1996). including the deceased patient’s family members and staff. D. Walker. 345–356. & Milligan.J. “It’s only human to hurt.com/NCEU/courses/grief/ Puckett. The results would be less burnout and less unhappy non-caring nurses. The grieving process needs to be recognized by nursing and health administration as a necessity for good health.nursingceu.” Hospitals need to recognize the need for grieving support groups where multidisciplinary teams are involved to include nursing. Please cry with me: Six ways to grieve. As a result. dying. (2003). 2003). Hinds. 292–296. . (1985). the concept of the grieving process as presented in this paper is related to nurses who experience the loss of a patient. Recognizing that nurses need to work through the grieving process and come to a healthy resolution with a patient’s death is the first step to helping maintain physical. D. C. from http://www.. Dimensions of Critical Care Nursing.A.O. it’s okay for you to grieve too. P. 56.